Citation Nr: 1625067 Decision Date: 06/22/16 Archive Date: 07/11/16 DOCKET NO. 13-17 803 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a vision disorder, to include as secondary to service-connected diabetes mellitus. 2. Entitlement to service connection for bilateral hearing loss. 3. Entitlement to service connection for bilateral tinnitus. 4. Entitlement to service connection for ischemic heart disease, to include as due to herbicide exposure. 5. Entitlement to an increased initial rating for posttraumatic stress disorder (PTSD), currently evaluated as 30 percent disabling. 6. Entitlement to an increased initial rating for diabetes mellitus, type II with erectile dysfunction and chronic kidney disease, currently rated as 20 percent disabling. 7. Entitlement to an increased initial rating for peripheral neuropathy of the right upper extremity, currently rated as 10 percent disabling. 8. Entitlement to an increased initial rating for peripheral neuropathy of the left upper extremity, currently rated as 10 percent disabling. 9. Entitlement to an increased initial rating for peripheral neuropathy of the right lower extremity, currently rated as 10 percent disabling. 10. Entitlement to an increased initial rating for peripheral neuropathy of the left lower extremity, currently rated as 10 percent disabling. 11. Entitlement to a compensable rating for inflammation of the cornea. 12. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Christopher L. Loiacono, Agent ATTORNEY FOR THE BOARD Ryan Frank, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Air Force from July 1970 to April 1974, including service in the Vietnam War. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. In his June 2013 substantive appeal (VA Form 9), the Veteran requested a hearing before the Board at the RO. However, the Board's records indicate that the Veteran withdrew his request for a hearing. Additionally, the Board notes that the Veteran did not appear at the hearing and he did not present good cause for his failure to appear, nor did he request that the hearing be rescheduled. The Board therefore deems his hearing request withdrawn pursuant to 38 C.F.R. § 20.702(d), (e) (2015). This appeal was processed using the Veterans Benefits Management System (VBMS) and Virtual VA paperless claims processing systems. Accordingly, any future consideration of the Veteran's case should take into account those electronic records. The issues of entitlement to increased ratings for PTSD and erectile dysfunction; service connection for a vision disorder; and TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. In an April 2008 rating decision, the RO previously considered and denied service connection for a vision disorder. 2. The Veteran was notified of the April 2008 rating decision and of his appellate rights, but he did not appeal that determination. There was also no evidence received within one year of that determination. 3. The evidence received since the April 2008 rating decision, by itself, or in conjunction with previously considered evidence, relates to an unestablished fact necessary to substantiate the claim for service connection for a vision disorder. 4. The Veteran has not been shown to currently have a current hearing loss disability for VA compensation purposes. 5. The Veteran has not been shown to currently have bilateral tinnitus that manifested in service or that is causally or etiologically related to his military service. 6. The Veteran served in the Republic of Vietnam during a period in which herbicide exposure is presumed. 7. The Veteran has not been shown to currently have ischemic heart disease. 8. The Veteran's diabetes mellitus, type II has not required regulation of activities. 9. The Veteran's chronic kidney disease has not resulted in constant or recurring albumin with hyaline and granular casts or red blood cells, transient or slight edema, or hypertension at least 10 percent disabling under Diagnostic Code 7101. 10. The Veteran's peripheral neuropathy of the right upper extremity has not resulted in more than mild incomplete paralysis of the median nerve. 11. The Veteran's peripheral neuropathy of the left upper extremity has not resulted in more than mild incomplete paralysis of the median nerve. 12. The Veteran's peripheral neuropathy of the right lower extremity has not resulted in more than mild incomplete paralysis of the sciatic nerve. 13. The Veteran's peripheral neuropathy of the left lower extremity has not resulted in more than mild incomplete paralysis of the sciatic nerve. 14. The Veteran's inflammation of the cornea has not resulted in any incapacitating episodes or visual impairment. CONCLUSIONS OF LAW 1. The April 2008 rating decision, which denied service connection for a vision disorder, is final. 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. §§ 3.156, 20.200, 20.201, 20.302, 20.1103 (2015). 2. The evidence received subsequent to the April 2008 rating decision is new and material, and the claim for service connection for a vision disorder is reopened. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156(a) (2015). 3. Bilateral hearing loss was not incurred in active service and sensorineural hearing loss may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.309, 3.385 (2015). 4. Bilateral tinnitus was not incurred in active service and may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.309. 5. Ischemic heart disease was not incurred in active service and may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1116 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2015). 6. The criteria for an initial evaluation in excess of 20 percent for diabetes mellitus have not been met or approximated for the period on appeal. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.119, Diagnostic Code 7913 (2015). 7. The criteria for a separate compensable evaluation for chronic kidney disease have not been met or approximated for the period on appeal. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.104, Diagnostic Code 7101, 4.115b, Diagnostic Code 7541 (2015). 8. The criteria for an initial evaluation in excess of 10 percent for peripheral neuropathy of the right upper extremity have not been met or approximated for the period on appeal. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.124a, Diagnostic Code 8515 (2015). 9. The criteria for an initial evaluation in excess of 10 percent for peripheral neuropathy of the left upper extremity have not been met or approximated for the period on appeal. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.124a, Diagnostic Code 8515. 10. The criteria for an initial evaluation in excess of 10 percent for peripheral neuropathy of the right lower extremity have not been met or approximated for the period on appeal. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.124a, Diagnostic Code 8520 (2015). 11. The criteria for an initial evaluation in excess of 10 percent for peripheral neuropathy of the left lower extremity have not been met or approximated for the period on appeal. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.124a, Diagnostic Code 8520. 12. The criteria for a compensable evaluation for inflammation of the cornea have not been met or approximated for the period on appeal. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.79, Diagnostic Code 6001 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant of what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A (West 2014); 38 C.F.R. § 3.159(b) (2015); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In this case, the RO provided the Veteran with notification letters in October 2010, prior to the initial decisions on the claims. Therefore, the timing requirement of the notice as set forth in Pelegrini has been met and to decide the appeal would not be prejudicial to the claimant. Moreover, the requirements with respect to the content of the notice were met in this case. In the letter, the RO notified the Veteran of the evidence necessary to substantiate the claims and of the division of responsibilities in obtaining such evidence. The letter also explained how disability ratings and effective dates are determined. Thus, VA's duty to notify has been satisfied with respect to the issues of entitlement to service connection for bilateral hearing loss, bilateral tinnitus, and ischemic heart disease, as well as the request to reopen the claim of entitlement to service connection for a vision disorder. With respect to the claims for increased evaluations, the Veteran in this case is challenging the initial evaluations assigned following the grants of service connection for diabetes mellitus, kidney disease, and peripheral neuropathy, as well as the preexisting evaluation for inflammation of the cornea. In Dingess, the Court held that, in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required as the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 490-91. See also VAOPGCPREC 8-2003 (December 22, 2003). Thus, VA's duty to notify has been satisfied with respect to the issues of entitlement to higher evaluations for diabetes mellitus, kidney disease, peripheral neuropathy, and inflammation of the cornea. In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records and all identified, relevant, and available post-service medical records have been associated with the claims file and were reviewed by both the AOJ and the Board in connection with the claim. The Veteran has not identified any other outstanding records that are pertinent to the issues currently on appeal. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the Veteran was afforded VA examinations of his ears, diabetes mellitus, kidneys, peripheral nerves, and eyes in November 2010. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examination reports are adequate to decide the case because, as shown below, the examinations were based upon consideration of the Veteran's pertinent medical history, as well as his lay assertions and current complaints, and the examiners described the Veteran's ears, diabetes mellitus, kidneys, peripheral nerves, and eyes in sufficient detail to allow the Board to make fully informed determinations. The examiners also provided the necessary opinions supported by rationale. Id; see Monzingo v. Shinseki, 26 Vet.App. 97, 105 (2012) (holding that "examination reports are adequate when they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion"). Under McLendon, 20 Vet. App. 79, in disability compensation claims, VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. Because, as will be explained below, there is no competent evidence of a current heart disability or persistent or recurrent symptoms of such a disability, the standards of McLendon are not met with respect to the claim for service connection for ischemic heart disease. The Board also finds that the Veteran has not asserted a worsening in the severity of any of the issues on appeal since November 2010, when he was last examined. 38 C.F.R. § 3.327(a) (2015). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See Palczewski v. Nicholson, 21 Vet.App. 174, 180 (2007) (submission of new evidence or allegation that the disability has worsened may require new medical examination to be provided, but "mere passage of time" does not). In a June 2013 statement, the Veteran's representative stated a general intent to seek and submit new evidence but, in the three years since that statement, VA has not received any such evidence from the Veteran or his representative. See Wood v. Derwinski, 1 Vet.App. 190, 193 (1991) (holding that VA's duty to assist is not "a one-way street"). Thus, there is adequate medical evidence of record to make a determination in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations or opinions with regard to the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4) (2015). The Board concludes that the Veteran was provided the opportunity to meaningfully participate in the adjudication of his claim, and he did, in fact, participate. Washington v. Nicholson, 21 Vet. App. 191 (2007). For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. The Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this particular claim. He has been given ample opportunity to present evidence and argument in support of his claim. All relevant evidence necessary for an equitable disposition of the Veteran's appeal of this issue has been obtained, and the case is ready for appellate review. General due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2015). II. New and Material Evidence Initially, the Board observes that the Veteran's claim of service connection for a vision disorder was previously considered and denied by the RO in a rating decision dated in April 2008. The Veteran was notified of that decision and of his appellate rights; however, he did not submit a notice of disagreement. In general, rating decisions that are not timely appealed are final. See 38 U.S.C.A. § 7105; 38 C.F.R. § 20.1103. There was also no evidence received within one year of the issuance of the decision. Therefore, the rating decision is final. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.156(b), 20.200, 20.201, 20.302, 20.1103. In September 2010, the Veteran requested that his claim of service connection for a vision disorder be reopened. The evidence of record at the time of the April 2008 rating decision included the Veteran's service and VA treatment records as well as a January 2006 VA examination report. In the April 2008 rating decision, the RO found that the Veteran had not established entitlement to service connection for diabetes mellitus and that, as a result, he could not establish entitlement to service connection for a vision disorder that was secondary to diabetes mellitus. The evidence associated with the claims file subsequent to the April 2008 rating decision includes a November 2010 VA examination report and the RO's May 2011 rating decision, which granted service connection for diabetes mellitus. This is new evidence, in that it was not previously of record and is not cumulative or redundant of the evidence already considered. With regard to whether the evidence is material, the Board notes that the threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). The RO's April 2008 rating decision with regard to a vision disorder was based in part on the fact that the Veteran was not service-connected for diabetes mellitus. This is no longer true. Accordingly, the Board finds that new and material evidence has been presented to reopen the Veteran's previously denied claim of service connection for a vision disorder. III. Service Connection A. Governing Law Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military, naval or air service. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. § 3.303(a) (2015). Service connection may be granted for any disease diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in active service. 38 C.F.R. § 3.303(d) (2015). Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007); Hickson v. West, 12 Vet. App. 247, 252 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Additionally, claims for certain chronic diseases - namely those listed in 38 C.F.R. § 3.309(a) - benefit from a somewhat more relaxed evidentiary standard under 38 C.F.R. § 3.303(b). A recent decision of the U. S. Court of Appeals for the Federal Circuit, clarified that this notion of continuity of symptomatology since service under 38 C.F.R. § 3.303(b), which as mentioned is an alternative means of establishing the required nexus or linkage between current disability and service, only applies to conditions identified as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and, when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). B. Hearing Loss The threshold for normal hearing is from 0 to 20 decibels; higher thresholds show some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). For the purpose of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, and 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. According to VA policy, sensorineural hearing loss is an "organic disease of the nervous system and is subject to presumptive service connection" under 38 C.F.R § 3.309(a). See M21-1 III.iv.4.B.3.a. In this case, the Veteran's service treatment records do not document any complaints, treatment, or diagnosis of hearing loss. The Veteran's service treatment records do not contain a separation examination. A May 1970 entrance examination found the Veteran's ears to be normal, and on the authorized audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 0 0 Not tested 0 LEFT 0 0 5 Not tested 15 In a December 2001 VA treatment record, the Veteran denied any hearing problem but acknowledged his family's and girlfriend's contention that he had one and admitted difficulty hearing when there is competing noise. A hearing examination showed hearing within normal limits other than unspecified mild losses at 4000 Hertz and 6000 Hertz in the right ear and at 6000 Hertz in the left ear. During a November 2010 VA examination, the Veteran reported the he had difficulty understanding speech and that he had to increase the volume on his television set to hear it. The examiner noted clear external auditory canals and normal tympanograms in both ears. An audiogram revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 5 20 20 LEFT 15 15 20 25 25 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and 94 percent in the left ear. The examiner specifically indicated that the audiogram showed normal hearing sensitivity in both ears. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. § 1110. Thus, the threshold question that must be addressed here (as with any claim seeking service connection) is whether the Veteran actually has the disability for which service connection is sought. In the absence of proof of a present disability, there is no valid claim of service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Degmetich v. Brown, 104 F.3d 1328 (1997). In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for bilateral hearing loss. As shown above, no evidence of record establishes the existence of a hearing loss disability under the clear requirements of 38 C.F.R. § 3.385 as set forth above. The evidence of record does not indicate that the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, and 4000 Hertz is 40 decibels or greater, that the auditory thresholds for at least three of these frequencies are 26 decibels or greater, or that speech recognition scores using the Maryland CNC Test are less than 94 percent. In Palczewski v. Nicholson, 21 Vet. App. 174, 178-80 (2007), the Court specifically upheld the validity of 38 C.F.R. § 3.385 to define hearing loss for VA compensation purposes. The Board acknowledges the Veteran's competent reported history of his in-service noise exposure and subsequent hearing difficulties. Nonetheless, while laypersons are sometimes competent to provide opinions regarding etiology and diagnosis, see Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007), in this case, the Board finds that the Veteran is not competent to offer an opinion as to whether he has a current hearing loss disability for VA purposes, as that matter requires specific audiological testing performed by state-licensed audiologists under certain guidelines and conditions, id at 1377 ("Whether lay evidence is competent and sufficient in a particular case is a fact issue to be addressed by the Board rather than a legal issue to be addressed by the Veterans' Court."). Based on the foregoing, the Board finds that the weight of the evidence is against the Veteran's claim. As such, the benefit-of-the-doubt rule does not apply, and the claim is denied. Gilbert, 1 Vet. App. 49, 53. C. Tinnitus The United States Court of Appeals for Veterans Claims has held that tinnitus is also an "organic disease of the nervous system" for the purposes of 38 C.F.R. § 3.309(a). Fountain v. McDonald, 27 Vet. App. 258, 271 (2015). In this case, the Veteran's service treatment records do not document any complaints, treatment, or diagnosis of tinnitus. The Veteran's service treatment records do not contain a separation examination. A May 1970 entrance examination found the Veteran's ears to be normal. In a December 2001 VA treatment record, the Veteran denied tinnitus. During a November 2010 VA examination, the Veteran reported that his tinnitus started approximately 20 years prior and that there were no particular circumstances of onset. The examiner noted clear external auditory canals and normal tympanograms in both ears. The examiner indicated that the audiogram showed normal hearing sensitivity in both ears. The examiner opined that it was less likely than not that the Veteran's tinnitus was a result of active duty service. The examiner's rationale was that the Veteran reported that his tinnitus did not have its onset until more than a decade after separation from service. The Veteran has not contended that the November 2010 VA examination was inadequate or incorrect, or that his condition has changed since that date. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for bilateral tinnitus. The Board acknowledges the Veteran's competent reported history of his in-service noise exposure and subsequent tinnitus. Jandreau, 492 F.3d 1376-77. However, the November 2010 VA examiner specifically cited the Veteran's report of the onset of his symptoms as the rationale for her opinion that tinnitus was not related to service. Moreover, the Board finds that the Veteran's statements as to the onset of his tinnitus and denial of tinnitus in December 2001 weigh against a finding of continuity of symptomatology since service. See Washington v. Nicholson, 19 Vet.App. 362, 367-68 (2005) (noting that it is the Board's duty, as factfinder, to assess the credibility and probative weight of all relevant evidence). Based on the foregoing, the Board finds that the weight of the evidence is against the Veteran's claim. As such, the benefit-of-the-doubt rule does not apply, and the claim is denied. Gilbert, 1 Vet. App. 49, 53. D. Ischemic Heart Disease A veteran who served in the Republic of Vietnam between January 9, 1962, and May 7, 1975, shall be presumed to have been exposed during such service to Agent Orange, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 U.S.C.A. § 1116(f); 38 C.F.R. §§ 3.307(a)(6)(iii), 3.307(d). "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii). In such circumstances, service connection may be granted on a presumptive basis for the diseases listed in 38 C.F.R. § 3.309(e). Ischemic heart disease is listed in 38 C.F.R. § 3.309(e). The Veteran's service records confirm that he served in the Republic of Vietnam during a period in which herbicide exposure is presumed. The Veteran's service treatment records show no complaints, treatment, or diagnosis of any heart disorder. The Veteran's service treatment records do not contain a separation examination. A May 1970 entrance examination found the Veteran's heart to be normal. During an April 2008 private treatment appointment, the treatment provider noted an "[e]ssentially normal stress myoview study without any evidence of ischemia or infarction based on the nuclear images obtained." During an August 2010 private treatment appointment, the treatment provider noted that a CT scan showed the Veteran's heart to be normal. The Veteran has not contended that these records are incorrect or that his condition has changed since that date. As stated above, the existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. § 1110. Thus, the threshold question that must be addressed here (as with any claim seeking service connection) is whether the Veteran actually has the disability for which service connection is sought. In the absence of proof of a present disability, there is no valid claim of service connection. See Brammer, 3 Vet. App. at 225; see also Degmetich, 104 F.3d at 1328. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for ischemic heart disease. As shown above, no evidence of record establishes the existence of ischemic heart disease. The Board acknowledges that laypersons are sometimes competent to provide opinions regarding etiology and diagnosis, see Jandreau, 492 F.3d at1 376-77. However, here, the Board finds that the question of whether the Veteran has a diagnosis of ischemic heart disease is a complex medical question outside the realm of lay observation. Id. at 1377. Based on the foregoing, the Board finds that the weight of the evidence is against the Veteran's claim. As such, the benefit-of-the-doubt rule does not apply, and the claim is denied. Gilbert, 1 Vet. App. 49, 53. IV. Increased Rating A. Governing Law Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. When the rating schedule does not provide a zero percent evaluation for a diagnostic code, a noncompensable evaluation shall be assigned when the requirements for compensable evaluation are not met. 38 C.F.R. § 4.31 (2015). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, as in this case, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the question for consideration is a higher initial rating since the grant of service connection, evaluation of the medical evidence since the grant of service connection to consider the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). B. Diabetes Mellitus Rating The Veteran's service-connected diabetes mellitus is rated 20 percent disabling, effective September 20, 2010. For diabetes mellitus requiring insulin and restricted diet, or requiring an oral hypoglycemic agent and a restricted diet, a 20 percent rating is warranted. 38 C.F.R. § 4.119, Diagnostic Code 7913. For diabetes mellitus requiring insulin, a restricted diet, and regulation of activities, a 40 percent rating is warranted. Id. Any rating higher than 40 percent requires other factors in addition to those three. Id. Regulation of activities is described as "avoidance of strenuous occupational and recreational activities." Id. Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360, 363-64 (2007). Thus, in order for an increased rating to be warranted, the evidence must show that the Veteran's activities are regulated as a result of his diabetes mellitus. During a January 2006 VA examination, the Veteran reported that hypoglycemic episodes resulting in automobile accidents had led him to retire from his employment and that his most recent episode had been three months prior to the examination. The examiner determined that the Veteran was able to engage in activities of daily living without restriction. During a November 2010 VA examination, the Veteran reported that he experienced mild hypoglycemia approximately once per month but had not experienced one sufficient to require an emergency room visit since 2006. The Veteran described no recent restriction of activities related to diabetes. The Veteran has not contended that the VA examiners were incorrect or that his condition has changed since the most recent VA examination. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to a rating in excess of 20 percent at any point during the period on appeal. The aforementioned evidence does not show that the Veteran's activities are regulated as a result of his diabetes mellitus. Although the Veteran is competent to report on matters observed or within his personal knowledge, see Layno v. Brown, 6 Vet. App. 465, 470 (1994), as noted above, a finding of regulation of activities requires medical evidence, a matter within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). There is no medical evidence that the Veteran's activities have been regulated as a result of his diabetes at any point during the period on appeal. Additionally, the Board notes that, even if the Veteran's lay reports of hypoglycemic episodes were sufficient to establish regulation of activities, those reports indicate that he ceased to have episodes of more than mild severity after 2006, long before the period on appeal. Accordingly, the Board finds that the schedular criteria for the next higher, 40 percent disability evaluation have not been met. The Board therefore finds that the preponderance of evidence is against the Veteran's claim for an initial evaluation in excess of 20 percent for diabetes mellitus. As the preponderance of the evidence is against a finding that a 40 percent evaluation is appropriate, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. C. Kidney Disease Rating The Veteran's service-connected chronic kidney disease is rated noncompensable as part of his rating for diabetes mellitus, effective September 20, 2010. Pursuant to 38 C.F.R. § 4.115b, Diagnostic Code 7541, a noncompensable rating for renal involvement in diabetes mellitus is warranted for albumin and cases with history of acute nephritis; or, hypertension noncompensable under diagnostic code 7101. A 30 percent rating is warranted for albumin constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under Diagnostic Code 7101 (diastolic pressure predominately 100 or more; systolic pressure predominately 160 or more; or a history of diastolic pressure predominantly 100 or more which requires continuous medication for control). A 60 percent rating is warranted for constant albuminuria with some edema; or, definite decrease in kidney function; or hypertension at least 40 percent disabling under diagnostic code 7101. An 80 percent rating is warranted for persistent edema and albuminuria with BUN 40 to 80 mg; or creatinine 4 to 8 mg; or generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent rating is warranted for renal dysfunction requiring regular dialysis, or precluding more that sedentary activity from one of the following; persistent edema and albuminuria; or, BUN more than 80 mg; or, creatinine more than 8 mg; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. Id. During a November 2010 VA examination, the examiner noted no history of proteinuria and microalbumin of 4 mg. The examiner found no peripheral edema. The examiner noted no history of hypertension or heart disease; the Veteran's blood pressure was 112/80 sitting, 100/80 supine, and 90/70 standing. The Veteran's BUN was 25 mg and creatinine was 1.4 mg. The Veteran reported no episodes of lethargy, weakness, anorexia, or weight change related to renal dysfunction. The examiner found no history of any requirement for dialysis. The Veteran has not contended that the VA examination was inadequate or incorrect, or that his condition has changed since the most recent VA examination. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to a separate compensable rating for chronic kidney disease at any point during the period on appeal. The aforementioned evidence does not show that the Veteran meets any of the schedular criteria for a compensable rating. The Board acknowledges the Veteran's competent reported history of his symptoms. Jandreau, 492 F.3d 1376-77. However, the November 2010 VA examiner specifically cited the Veteran's lay reports, none of which contained symptoms sufficient to warrant a compensable rating. Accordingly, the Board finds that the schedular criteria for the next higher, 30 percent disability evaluation have not been met. The Board therefore finds that the preponderance of evidence is against the Veteran's claim for an initial compensable evaluation for chronic kidney disease. As the preponderance of the evidence is against a finding that a 30 percent evaluation is appropriate, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. D. Peripheral Neuropathy Ratings The Veteran's service-connected peripheral neuropathy is rated 10 percent disabling in each extremity, effective September 20, 2010. The Veteran's peripheral neuropathy is rated under 38 C.F.R. § 4.124a, Diagnostic Code 8515 for the upper extremities and 38 C.F.R. § 4.124a, Diagnostic Code 8520 for the lower extremities. Pursuant to Diagnostic Code 8515, a 10 percent rating is warranted for mild incomplete paralysis of the median nerve, a 20 percent rating is warranted for moderate incomplete paralysis of the median nerve in the minor extremity, a 30 percent rating is warranted for moderate incomplete paralysis in the major extremity, a 40 percent rating is warranted for severe incomplete paralysis in the minor extremity, a 50 percent rating is warranted for severe incomplete paralysis in the major extremity, a 60 percent rating is warranted for complete paralysis in the minor extremity, and a 70 percent rating is warranted for complete paralysis in the major extremity. 38 C.F.R. § 4.124a, Diagnostic Code 8515. Pursuant to Diagnostic Code 8520, a 10 percent rating is warranted for mild incomplete paralysis of the sciatic nerve, a 20 percent rating is warranted for moderate incomplete paralysis, a 40 percent rating is warranted for moderately severe incomplete paralysis, a 60 percent rating is warranted for severe incomplete paralysis with marked muscular atrophy, and an 80 percent rating is warranted for complete paralysis. 38 C.F.R. § 4.124a, Diagnostic Code 8520. During a November 2010 VA examination, the Veteran reported numbness in his knees and intermittent numbness in his fingers. He said that the numbness in his knees did not restrict his walking distance but he chose not to walk much due to knee and back symptoms. The examiner found that sensory perception in the Veteran's extremities was intact to fine touch and position, that temperature sense was decreased on the left and in a stocking-glove distribution, that vibration sense was mildly decreased on the left side and at the ankles, and that reflexes were at a level of 1-2+ other than an absent left ankle jerk reflex. The examiner diagnosed the Veteran with polyneuropathy and characterized the sensory loss in all four extremities as mild and incomplete. The Veteran has not contended that the VA examination was inadequate or incorrect, or that his condition has changed since the most recent VA examination. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to ratings greater than 10 percent for peripheral neuropathy in any extremity at any point during the period on appeal. The aforementioned evidence does not show that the Veteran has more than mild incomplete paralysis of the nerves in any extremity. The Board acknowledges the Veteran's competent reported history of his symptoms. Jandreau, 492 F.3d 1376-77. However, the November 2010 VA examiner specifically cited the Veteran's lay reports, none of which contained symptoms sufficient to warrant a rating greater than 10 percent. Accordingly, the Board finds that the schedular criteria for the next higher, 20 percent disability evaluations have not been met. The Board therefore finds that the preponderance of evidence is against the Veteran's claim for an initial evaluation in excess of 10 percent for his service-connected peripheral neuropathy in each extremity. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. E. Cornea Rating The Veteran's service-connected inflammation of the cornea is rated noncompensable, effective August 13, 2001. Pursuant to 38 C.F.R. § 4.79, Diagnostic Code 6001, any compensable rating requires incapacitating episodes. The rating schedule defines an incapacitating episode as "a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other healthcare provider." During a November 2010 VA examination, the Veteran reported that he had suffered from chronic conjunctivitis during his active duty service but, after his return from Vietnam, the conjunctivitis cleared up and he had experienced no subsequent symptoms. The Veteran has not contended that the VA examination was inadequate or incorrect, or that his condition has changed since the most recent VA examination. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to a compensable rating for inflammation of the cornea at any point during the period on appeal. The aforementioned evidence does not show that the Veteran has had any incapacitating episodes due to inflammation of the cornea during the period on appeal. The Board acknowledges the Veteran's competent reported history of his symptoms. Jandreau, 492 F.3d 1376-77. However, the November 2010 VA examiner specifically cited the Veteran's lay report that he had experienced no symptoms since his return from Vietnam. Accordingly, the Board finds that the schedular criteria for a compensable evaluation have not been met. The Board therefore finds that the preponderance of evidence is against the Veteran's claim for a compensable rating for inflammation of the cornea. As the preponderance of the evidence is against a finding that a compensable evaluation is appropriate, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. F. Extraschedular Consideration In reaching this decision, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In particular, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1). However, in this case, the Board finds that the record does not show that the Veteran's diabetes mellitus, chronic kidney disease, peripheral neuropathy, or inflammation of the cornea are so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service- connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extraschedular regulation (38 C.F.R. §3.321(b)(1)) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disabilities are inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned ratings with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The manifestations of the Veteran's diabetes mellitus, including a need for an insulin pump and occasional mild hypoglycemia, are contemplated by the schedular criteria set forth in Diagnostic Code 7913. The manifestations of the Veteran's chronic kidney disease, including an increase in serum creatinine, are contemplated by the schedular criteria set forth in Diagnostic Code 7541. The manifestations of the Veteran's peripheral neuropathy, including numbness, are contemplated by the schedular criteria set forth in Diagnostic Codes 8515 and 8520. The manifestations of the Veteran's inflammation of the cornea, which is asymptomatic, are contemplated by the schedular criteria set forth in Diagnostic Code 6001. The Board further notes that, under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. However, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for any additional disability that can be attributed only to the combined effect of multiple conditions insofar as they impact the disability picture of the disability presently on appeal. See Yancy v. McDonald, 27 Vet.App. 484, 495 (2016) (clarifying that, "although Johnson requires the Board, in certain cases, to discuss the collective impact of a claimant's service-connected disabilities, it does not alter the Board's jurisdiction over individual schedular or extraschedular ratings."). Significantly, the Veteran and his representative have not identified any symptoms resulting from the combined effect of his service-connected disabilities that are not contemplated by his assigned disability ratings. Consequently, on this record, referral for extraschedular consideration is not required under 38 C.F.R. § 3.321(b)(1) for this disability. Therefore, the threshold factor for extraschedular consideration under step one of Thun has not been met. The disability picture is contemplated by the rating schedule and the assigned schedular ratings are, therefore, adequate. Consequently, on this record, referral for extraschedular consideration is not required under 38 C.F.R. § 3.321(b)(1) for these disabilities. Based on the foregoing, the Board finds that the requirements for an extraschedular evaluation for the Veteran's service-connected diabetes mellitus, chronic kidney disease, peripheral neuropathy, or inflammation of the cornea under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun, 22 Vet. App. at 111. ORDER An initial evaluation in excess of 20 percent for diabetes mellitus with chronic kidney disease is denied. An initial evaluation in excess of 10 percent for peripheral neuropathy of the right upper extremity is denied. An initial evaluation in excess of 10 percent for peripheral neuropathy of the left upper extremity is denied. An initial evaluation in excess of 10 percent for peripheral neuropathy of the right lower extremity is denied. An initial evaluation in excess of 10 percent for peripheral neuropathy of the left lower extremity is denied. A compensable evaluation for inflammation of the cornea is denied. Service connection for bilateral hearing loss is denied. Service connection for bilateral tinnitus is denied. Service connection for ischemic heart disease is denied. New and material evidence having been submitted, the claim of entitlement to service connection for a vision disorder is reopened, and, to this extent only, the appeal is granted. REMAND The evidence currently of record does not include any VA treatment records between August 2010 and September 2015. An October 2015 VA treatment record indicates that the Veteran may have been participating in treatment for his PTSD through VA since August 2011. For that reason, a remand is necessary so that the AOJ may attempt to secure the Veteran's treatment records. The Veteran's erectile dysfunction is rated noncompensable as part of his rating for diabetes mellitus. In order to warrant a compensable rating for erectile dysfunction under 38 C.F.R. § 4.115b, Diagnostic Code 7522 (2015), there must be evidence of penile deformity with a loss of erectile power. During a January 2006 VA examination, the examiner noted Peyronie's disease of the penis but opined that it was unrelated to diabetes mellitus. The examiner, however, offered no rationale for this opinion. During a November 2010 VA examination, the examiner also noted Peyronie's disease, but offered no opinion as to its etiology. Therefore, the Board finds that an additional medical opinion is needed. Having reopened the claim of entitlement to service connection for a vision disorder, the Board finds that a remand is warranted for additional due process considerations. The United States Court of Appeals for Veterans Claims has held that, before the Board may address a matter that has not been addressed by the AOJ, it must consider whether the veteran has been given adequate notice of the need to submit evidence or argument on that question and an opportunity to submit such evidence and argument at a hearing, and, if not, whether the claimant has been prejudiced thereby. Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this case, the AOJ has not considered the claim for service connection for a vision disorder on the merits in light of the newly submitted evidence. As such, a remand is warranted so that the AOJ can do so without prejudice to the Veteran. Finally, the Board notes that in an attachment to his January 2012 notice of disagreement, the Veteran's representative "ask[ed] that due consideration [be] given to the issue of individual unemployability." Although the RO denied TDIU in a December 2015 rating decision, as the issue of TDIU is part and parcel of a claim for a higher evaluation, see Rice v. Shinseki, , 22 Vet.App. 447, 454-55 (2009) (TDIU "is part and parcel of the determination of the initial rating for [a] disability"), the issue of the Veteran's entitlement to TDIU is properly before the Board. However, the issue of entitlement to a TDIU is inextricably intertwined with the claims being remanded. In other words, resolution of the remanded issues may impact the issue of TDIU. See Smith (Daniel) v. Gober, 236 F.3d 1370, 1373 (Fed. Cir. 2001) (noting that where the facts underlying separate claims are "intimately connected," the interests of judicial economy and avoidance of piecemeal litigation require that the claims be adjudicated together); see also Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (finding that two or more issues are inextricably intertwined if one claim could have significant impact on the other). Action on the issue of TDIU is therefore deferred. Accordingly, the case is REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for PTSD, erectile dysfunction, or a vision disorder. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. 2. The AOJ should secure any outstanding VA treatment records, to specifically include those between August 2010 and September 2015. 3. After securing any treatment records, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected erectile dysfunction. Any studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and the Veteran's own assertions. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the Veteran's disability under the rating criteria, including whether there is an evident deformity of the penis, whether it is at least as likely as not that any such deformity is caused or aggravated by a service-connected disability, and whether any deformity is accompanied by loss of erectile power. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. As it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1, copies of all pertinent records in the Veteran's claims file, or, in the alternative, the entire claims file, must be made available for review. 4. Adjudicate on the merits the claim for entitlement to service connection for a vision disorder; if it is determined that an examination and opinion is indicated, such examination should be undertaken, in accordance with applicable procedures. 5. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims must be readjudicated, including the issue of the Veteran's entitlement to TDIU. If the claim remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ ANTHONY C. SCIRÉ, JR. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs